19 September 2011

A hard thing about being an ER doctor is that I know a little, sometimes very little, about a lot of things. When I am faced with a particular condition, I often need to call the specialist for that organ, who knows way way more about it than I ever will, and they all think I'm an idiot because I don't know as much about their organ as they do. There's a huge asymmetry of knowledge, and it can create some tension and conflict.

I'm OK with it, because I can ignore their condescension and I am secure with what I do know, and its limits. But sometimes I get perplexing instructions from the specialists. The emergency medicine dogma can be overbroad and a little hidebound and what the specialists will do in the real world often radically diverges from what the Emergency Medicine textbooks say to do. It's often an interesting learning opportunity for me, especially when it's a condition I don't encounter that much. But I also have to work to maintain a flexible and open-minded attitude when I call a consultant and my side of the conversation consists of "Really? I didn't know you did that for this..." You need to know and trust your colleagues in other specialties, and know when to call BS on them and push to do something else, which is really hard to do when you are talking to someone who is so much more of an expert than you are.

So I saw this guy recently, a urban hipster who was perhaps a bit too old to be riding his longboard on the hilly streets of our fair town. He didn't seem to be too good at it, judging by the collection of crusted abrasions and aging ecchymoses he was sporting. He had been falling a lot recently -- we only get about a month of sun here, so I guess he was making the most of the summer weather practicing his new hobby. He had a variety of complaints from his recent falls, but it was a wound infection that had driven him to come in. A bit of road rash on his thigh was looking a bit cellulitic and I thought might benefit from some keflex.

I had to go through the motions of doing a more or less thorough exam, and he was pretty tender on his neck, I noticed. He said it had been hurting for about a week, since he had fallen backwards and hit his head on a car fender. He demonstrated how his neck was fully extended at the moment of impact, and the resolving goose egg on his scalp correlated. I wasn't terribly impressed by any of his orthopedic injuries, but I did order a few plain films, just to CYA, and I included a C-spine series as well, which is rare for me since if I really think someone might have a C-spine injury CT scanning is the imaging modality of choice.

I actually got a little short of breath when I scanned through his images and this jumped out at me:

For those not accustomed to reading these, this is a fracture through the posterior part of the second cervical vertebra, also known as a hangman's fracture. You might infer from the name that this is an unstable, bad injury, and you would be right. And our hipster friend had been walking around (hell, skating around and falling) for a full week with this injury! His neuro exam, I confirmed, was rock-solid normal. We popped a C-collar on him and I called the neurosurgeon at the local spine center to arrange transfer.

I had the opportunity to hold forth, as the nurses and techs gathered around the monitor to see the image, explaining that the "hangman's fracture" is a bit of a misnomer. Generally it is sustained from axial loading (as opposed to traction), which makes a ton of difference. The real-world mechanism is planting your forehead into a car windshield, that is, not hanging from a rope, and the spinal cord is typically uninjured in mechanisms of this sort. It's unstable and needs to be fixed, but there are many worse c-spine fractures you could have. My audience was very appreciative and I basked in their attention.

I was quite surprised, however, when I eventually spoke to the neurosurgeon. "It's a stable fracture," he told me, "he's had it for a week and his cord is fine. Put him in a hard collar and send him home. I'll see him in clinic next tuesday." It was one of those "What? Really?" moments I described above.

This surgeon, I should mention, was not some fly-by-night guy, nor was it the intern. He's a very respected professor at a university-affiliated trauma center. Not someone I am predisposed to argue with. I see hangman's fractures about, oh, once a decade, and he operates on them all the time. He clearly thought it was quite routine to send him home. And he did have a point -- it had been a week, after all. So with great discomfort, I acquiesced. For lay readers, it is important to understand that there are categories of stable spinal fractures that should go home, so it's not as crazy as it sounds. Not quite, anyway.

It seemed wrong, though, very wrong. I ran it by a couple of my partners and their eyes all got kind of big at the prospect, too. Without any clear plan, I decided to buy time and get the CT scan to better delineate the injury. After all, I reasoned, they will need it to plan the surgery when he goes to clinic next week. ("Next week? Am I really going to send a C2 fracture home for a week without even seeing the neurosurgeon? This is nuts! I just can't.") I chatted with the radiologist who read the CT, who described the hangman's fracture and blah blah blah, lots of technical details that meant nothing to me. I had radiology send the images electronically to the trauma center and sent a message to the surgeon that there was a scan available, in the hopes that might change his mind.

The surgeon called me back about ten minutes later, with a hint of anxiety in his voice. "Please tell me you didn't send that guy home, did you? This is a really bad, unstable injury. I need to operate on him today." To his credit, he had the grace to be embarrassed about his earlier advice and acknowledged that I was right to have stuck to my guns on this case.

I still don't claim to fully understand the intricacies of this injury or what about it changed the surgeon's mind. I'm not a neurosurgeon. I am very glad, though, that in this case I listened to my gut and that I didn't send him home. My malpractice carrier is, too. Knowing when to call BS, when to say "No" is one of the hardest things about my job, because it's pure instinct.

I have noticed over the years that that instinct, and the ability to follow it despite sometimes getting harsh words and derision from specialist, is one of the key defining points of good ER docs. I've noticed that ER docs that let specialist steam roll them get in a lot more trouble and get a lot less respect from those same specialists.

In twenty odd year I've seen maybe close to half a dozen hangman's fractures, maybe half of which were fatal. Never heard of one being sent home.

It's also kind of surprising that a neurosurgeon was willing to make that call on a single plain film. At that local spine center they always want CTs, then when the patient gets there they repeat the CT that was done an hour ago. Of course they are occasionally just a tad overworked down there, and I suppose bad calls are made on occasion.

Clearly you did the right thing. The plain film was enough for me. Little doubt that there was protective spasm and the neurosurgeon is initially making a judgement on the stability of the segment based on a static picture of 1 moment in time. The patient meanwhile is one slip away from the displacement of his dens into his brainstem. Every vertebral segment is a ring, rings don't break in only one place. It is not possible for it to be "stable" in the face of repeated movement. The patient was lucky 3 times: walking about without displacement, walking into the ER and having you on duty, & having the surgeon find his humility and an open OR.

My similar case was not so fortunate. She walked in a week post injury. During my history, she extended her neck to "find where it hurt" so she could point to it for me and severed her cord. How can an intern ever forget that patient, even 40 years later? Especially when she was the second patient that week with a week old neck injury. Patient number one walked in, went out a quad. Which is why I still tend to like C-collars on all patients who present with neck pain, regardless of the looks the nurses give me. Pam,EMP

That x-ray is enough to suggest that this is not the usual hangman's fracture that can be treated with a hard collar. There is a significant amount of anterior displacement of the C2 vertebral body on C3 and the alignment of the two vertebral bodies strongly suggests disruption of the C2-3 disc. Disruption of the ligaments and C2-3 disc are the most important indicators for instability requiring more aggressive treatment, such as surgery. As a neurosurgery resident I often grow exasperated (justified or not) at what I perceive as ER docs acting as triage without using clinical decision making. It is always good to see things from the other side, as a reminder that it can go both ways. Excellent call. This is a great example of why you always need to see the films yourself.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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